Form Account to Surname First Names Date of Birth Home Address Work Address Occupation Postal Address Tel(Work) Tel(Cell) Tel(Home) Email Spouse Surname First Names Date of Birth Home Address Work Address Occupation Postal Address Tel(Work) Tel(Cell) Tel(Home) Email MEDICAL AID Medical Aid Name Medical Aid Number Medical Aid Member Main Member ID Spouse ID DEPENDANTS Names Date of Births Remarks NEAREST FAMILY - FRIENDS Name Relationship Home Address Tel(Home) Work Address Tel(Work) MEDICAL HISTORY Name Date of birth Medical Practitioner Are you under care of a doctor? Please give details or leave blank if not Do you have any Allergies? (e.g. Penicillin, Sulphur) Are you at present on any Medication? —Please choose an option—YesNo Do you have any history of Anaemia Diabetes Asthma Lung Disease Diarrhoea Night Sweats Unexplained Fatigue Heart Condition Bleeding Abnormalities Grandular Enlargement Undiagnosed fever(s) Unexplained Weight Loss Do you believe or have you been informed that you belong to any high risk category patient group? Hepatitis Renal Disease Recent Blood Transfusion Do you believe that you have recently been exposed to any viral infections? If uncertain, please give full details as it is only in your own interest and the interest of your community.
